Daratumumab, Carfilzomib, and Dexamethasone (D-Kd) in Lenalidomiderefractory Patients with Relapsed Multiple Myeloma (MM): Subgroup Analysis of MMY11 Chari A, 1* Martinez-Lopez J, 2 Mateos M-V, 3 Bladé J, 4 Lonial S, 5 Benboubker L, 6 Oriol A, 7 Arnulf B, 8 Rodriguez-Otero P, 9 Pineiro L, 1 Jakubowiak A, 11 de Boer C, 12 Wang J, 13 Schecter J, 13 Moreau P 14 1 Tisch Cancer Institute, Mount Sinai School of Medicine, New York, NY, USA; 2 Hospital-12-de-Octubre, Madrid, Spain; 3 University Hospital of Salamanca/IBSAL, Salamanca, Spain; 4 Hospital Clínic de Barcelona, Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; 5 Winship Cancer Institute, Emory University, Atlanta, GA, USA; 6 Hôpital Bretonneau, Centre Hospitalier Régional Universitaire (CHRU), Tours, France; 7 Institut Català d Oncologia and Institut Josep Carreras, Hospital Germans Trias i Pujol, Barcelona, Spain; 8 Hôpital Saint Louis, APHP, Paris, France; 9 Clínica Universidad de Navarra-CIMA, IDISNA, Pamplona, Spain; 1 Texas Oncology-Baylor Charles A. Sammons Cancer Center, Dallas, TX, USA; 11 University of Chicago Medical Center, Chicago, IL, USA; 12 Janssen Biologics, Leiden, The Netherlands; 13 Janssen Research & Development, LLC, Raritan, NJ, USA; 14 University Hospital Hôtel-Dieu, Nantes, France These data were originally presented at the Annual Meeting of the American Society of Clinical Oncology (ASCO); June 1-5, 218; Chicago, Illinois. *presenting author Abstract
Disclosures AC consulted for Amgen, Array BioPharma, Celgene, Janssen, Millennium, Takeda, Novartis, Sanofi, and Karyopharm; and received research funding from Amgen, Array BioPharma, Celgene, Janssen, Millennium, Takeda, Novartis, and Pharmacyclics. JM-L consulted for Janssen and Celgene; and served on speakers bureaus for Janssen, Celgene, BMS, and Novartis. M-VM received honoraria from and consulted for Celgene, Janssen, Takeda, and Amgen. JB received honoraria from Janssen, Celgene, Amgen, and Takeda; received research funding from Janssen and Celgene; and received travel expenses from Janssen, Celgene, Amgen, and Takeda. SL consulted for Millennium, Celgene, Novartis, BMS, Janssen, Amgen, GSK, and Merck; and received research funding from Janssen, Millennium, and Celgene. LB consulted for and received honoraria from Takeda, Celgene, Amgen, and Janssen; and received travel expenses from Janssen, Celgene, and Amgen. AO consulted for and received honoraria from Amgen, Takeda, and Janssen; and served on speakers bureaus for Amgen and Janssen. BA received honoraria from Janssen, Amgen, and Celgene; and consulted for Amgen. LP served on speakers bureaus for Alexion and Seattle Genetics. AJ received honoraria from AbbVie, Amgen, BMS, Celgene, Janssen, Karyopharm, Sanofi, SkylineDx, and Takeda; and consulted for AbbVie, Amgen, BMS, Celgene, Janssen, Karyopharm, SkylineDx, and Takeda. CdB, JW, and JS are employees of Janssen. JS holds stock and/or stock options in J&J. PM consulted for and received honoraria from Celgene, Takeda, and Janssen. PR- O has no conflicts of interest to disclose. This study (ClinicalTrials.gov Identifier: NCT1998971) is funded by Janssen Research & Development, LLC. Medical writing and editorial support were provided by Jason Jung, PhD, of MedErgy, and were funded by Janssen Global Services, LLC.
Background Many recent phase 3 studies in relapsed or refractory multiple myeloma (RRMM) patients were lenalidomide (len)-based and excluded len-refractory patients 1 The increasing adoption of len maintenance highlights a need for large studies in lenrefractory RRMM patients 2 Based on subgroup analyses, several regimens have demonstrated varying degrees of efficacy in len-refractory patients 3-7 Daratumumab (DARA) is a human IgGκ monoclonal antibody targeting CD38 with a direct on-tumor and immunomodulatory mechanism of action that is approved in many countries as a monotherapy or combination therapy in patients with RRMM and in combination with bortezomib, melphalan, and prednisone for patients with newly diagnosed MM who are ineligible for autologous stem cell transplant 8,9 Carfilzomib (K) is a proteasome inhibitor (PI) approved for the treatment of RRMM patients 1 In combination with dexamethasone, once-weekly dosing with K 7 mg/m 2 demonstrated superior efficacy and comparable safety to twice-weekly dosing of K 27 mg/m 2 in RRMM patients 11 In newly diagnosed MM patients, DARA plus K/len/dexamethasone (KRd) was well tolerated and induced deep responses prior to elective ASCT 12 We examined the safety, pharmacokinetics, and efficacy of DARA in combination with K and dexamethasone (D-Kd) in len-refractory RRMM patients in MMY11 1. Harousseau JL, Attal M. Blood. 217;13(8):963-973; 2. Sengsayadeth S, et al. Blood Cancer J. 217;7(3):e545; 3. Moreau P, et al. Leukemia. 217;31(1):115-122; 4. Dimopoulos MA, et al. Lancet Oncol. 216;17(1):27-38; 5. Miguel JS, et al. Lancet Oncol. 213;14(11):155-166; 6. Lentzsch S, et al. Presented at: Annual Meeting of the Japanese Society of Hematology (JSH); October 2-22, 217; Tokyo, Japan; Abstract OS3-12D-2; 7. Facon T, et al. Presented at: American Society of Hematology (ASH) Annual Meeting; December 9-12, 217; Atlanta, GA, USA. Abstract 1824; 8. DARZALEX (daratumumab) injection, for intravenous use [package insert]. Horsham, PA: Janssen Biotech, Inc.; 218; 9. European Medicines Agency. Summary of opinion (post authorisation). DARZALEX (daratumumab); 218; 1. KYPROLIS (carfilzomib) [package insert]. Thousand Oaks, CA: Onyx Pharmaceuticals, Inc; 218; 11. Mateos MV, et al. Presented at: American Society of Clinical Oncology (ASCO) Annual Meeting; June 1-5, 218; Chicago, IL. Abstract 8; 12. Jakubowiak A, et al. Presented at: American Society of Clinical Oncology (ASCO) Annual Meeting; June 2-6, 217; Chicago, IL. Abstract 8.
Study Design and Treatment This was an open-label, nonrandomized, multicenter, phase 1b study of D-Kd for the treatment of patients with relapsed MM (Figure 1) Figure 1. Study design: MMY11 D-Kd treatment arm Eligibility/treatment Relapsed MM 1-3 prior lines of therapy, including bortezomib and an IMiD patients allowed Carfilzomib-naïve ECOG status 2 LVEF 4% ANC 1 1 9 /L Platelet count 75 1 9 /L DARA: Dosing schedule (28-day cycles) Split first dose a : 8 mg/kg Days 1-2 of Cycle 1 Single first dose: 16 mg/kg on Cycle 1 Day 1 16 mg/kg IV QW on Cycles 1-2, Q2W on Cycles 3-6, and Q4W thereafter until PD Carfilzomib b : 2 mg/m 2 IV Cycle 1 Day 1 Escalated to 7 mg/m 2 Cycle 1 Day 8+; weekly (Days 1, 8, 15) until PD Dexamethasone: 4 mg/week (Days 1, 8, 15, 22) IV or PO until PD Endpoints Primary Safety, tolerability Secondary ORR OS Exploratory PFS MRD (NGS) c PK D-Kd, daratumumab/carfilzomib/dexamethasone; MM, multiple myeloma; IMiD, immunomodulatory drug; len, lenalidomide; ECOG, Eastern Cooperative Oncology Group; LVEF, left ventricular ejection fraction; ANC, absolute neutrophil count; DARA, daratumumab; IV, intravenously; QW, weekly; Q2W, every 2 weeks; Q4W, every 4 weeks; PD, progressive disease; PO, orally; ORR, overall response rate; OS, overall survival; PFS, progression-free survival; MRD, minimal residual disease; NGS, next-generation sequencing; PK, pharmacokinetic; CR, complete response; IFE, immunofixation; VGPR, very good partial response. a In 5 ml dilution volume. b Both 2 mg/m 2 and 7 mg/m 2 were administered as 3-minute IV infusions. c Among patients evaluated for MRD, MRD was assessed using NGS at time of suspected CR and at 12 and 18 months after initial dose. In cases where DARA is suspected of interfering with IFE and preventing clinical CR response calls, subjects with VGPR may also be evaluated for MRD.
Baseline Demographics and Patient Disposition A total of 85 patients were enrolled in the study, including 51 patients who were len-refractory (Table 1) Demographics and clinical characteristics of len-refractory patients were representative of all treated patients Table 1. Patient Demographics and Baseline Characteristics. Characteristic (n = 51) All treated (N = 85) Median (range) age, y 66 (38-85) 66 (38-85) ECOG status, n (%) -1 2 47 (92) 4 (8) 78 (92) 7 (8) Prior lines of therapy, n (%) Median (range) 2 (1-4) 2 (1-4) Prior ASCT, n (%) 33 (65) 62 (73) Prior bortezomib, n (%) 51 (1) 85 (1) Prior IMiD, n (%) Lenalidomide Pomalidomide Thalidomide 51 (1) 51 (1) 9 (18) 11 (22) 85 (1) 81 (95) 13 (15) 21 (25) Prior PI + IMiD, n (%) 51 (1) 85 (1) Refractory to, n (%) a Lenalidomide Pomalidomide Bortezomib PI + IMiD 51 (1) 9 (18) 21 (41) 22 (43) 51 (6) 11 (13) 26 (31) 25 (29) Median (range) follow-up for the overall population was 12. (.5-23.2) months Patient disposition for all treated patients is summarized in Figure 2 A similar duration of follow-up and patient disposition was observed for the len-refractory cohort Figure 2. Patient disposition of all-treated patients DARA, daratumumab; Kd, carfilzomib/dexamethasone; AE, adverse event. a AEs leading to discontinuation of study treatment included grade 4 thrombocytopenia, grade 3 asthenia, grade 3 prostate cancer, and grade 2 back pain. ECOG, Eastern Cooperative Oncology Group; ASCT, autologous stem cell transplant; PI, proteasome inhibitor; IMiD, immunomodulatory drug. a Refractoriness was based on their most recent prior medication.
TEAEs, Infusion-related Reactions (IRRs), and Infusion Times Treatment-emergent Adverse Events (TEAEs) The most common (>25%) hematologic and nonhematologic TEAEs reported among all treated patients are summarized in the Table 2 patients treated with D-Kd demonstrated a similar safety profile to that of all treated patients Table 2. Most Common (>2%) TEAEs (All Treated). N = 85 Any grade, % Grade 3/4, % Thrombocytopenia 67 31 Anemia 47 21 Nausea 4 1 Upper respiratory tract infection 39 1 Asthenia 38 12 Vomiting 37 1 Dyspnea 34 2 Pyrexia 33 1 Insomnia 31 4 Diarrhea 31 2 Neutropenia 29 21 Lymphopenia 25 22 Hypertension 25 14 Cough 25 Headache 22 1 Back pain 22 Infusion-related Reactions (IRRs) and Infusion Rates (All Treated) IRR rates and median infusion times for the single and split first dose cohorts are summarized in Table 3 IRR rates and infusion times were consistent between single and split first dose for subsequent infusions Table 3. IRR and Infusion Rates (All Treated). Single first infusion (n = 1) Cycle 1 Day 1 Split first infusion (n = 75) Cycle 1 Day 1 Cycle 1 Day 2 IRR, infusion-related reaction. IRR, n (%) 5 (5.%) 27 (36.%) 3 (4.%) Low neutropenia rates with D-Kd in RRMM Similar safety profile observed for len-refractory patients Split first dose of DARA is feasible and improves patient convenience Median (range) infusion time 7.1 (6.5-8.9) h 4.3 (3.9-1.6) h 4.2 (3.9-8.6) h
Cardiac Function Echocardiogram assessment of left ventricular ejection fraction (LVEF) in all treated patients is shown in Table 4 Diastolic dysfunction was not consistently assessed Median (range) onset time of cardiac TEAEs was 191 (1-583) days One grade 4 AE (left ventricular failure; not DARA-related) resolved Five grade 3 AEs resolved (systolic dysfunction [2], cardiac failure, atrial fibrillation, and sinus tachycardia [1 each]) Two grade 3 AEs did not resolve (congestive cardiomyopathy and left ventricular dysfunction; not DARA-related) K was interrupted/withdrawn for all grade 3/4 cardiac AEs except for 1 case where only DARA was interrupted (grade 3 sinus tachycardia) Cardiac AEs improved in grade when K was interrupted Table 4. Echocardiogram Assessment in All Treated Patients. Echocardiogram assessment time point Baseline (n = 84) Cycle 6 (n = 53) Cycle 12 (n = 36) Cycle 18 (n = 8) Cycle 24 (n = 3) All treated patients LVEF, median (range) 64 (44-83) 62 (46-77) 6 (5-76) 6 (52-74) 6 (53-66) LVEF, left ventricular ejection fraction. No notable change in median LVEF was observed from baseline over time
ORR, % MRD-negative rate, % Results: Efficacy (Overall Response a and MRD-negative Rates) Deep responses were observed with D-Kd in all treated, len-refractory, and len-exposed patients (Figure 3A) Optional MRD testing was conducted in 11 patients who achieved CR or stringent CR; 4 patients achieved MRD negativity at 1 5 (Figure 3B) Figure 3. (A) ORR a and (B) MRD-negative rates at 1-5 in MRD-tested patients who achieved CR/sCR 1 9 8 7 6 5 4 3 2 1 CR 27% ORR = 84% 11% 16% 8% 1% 44% 5% 13% 1% All treated n = 82 PR VGPR CR scr CR 19% VGPR 71% ORR = 79% n = 48 CR 37% VGPR 69% ORR = 9% 17% 2% 37% 17% VGPR 73% Len-exposed but not refractory n = 3 6 5 4 3 2 1 4/11 pts 36% All treated n = 11 1/5 pts 2% n = 5 2/4 pts 5% Len-exposed but not refractory n = 4 Responses are anticipated to deepen over longer follow-up ORR, overall response rate; MRD, minimal residual disease; CR, complete response; scr, stringent complete response; PR, partial response; VGPR, very good partial response; len, lenalidomide; pts, patients. a In response-evaluable patients (received 1 administration of any component of study treatment and have 1 post-baseline disease assessment) who were treated with >2 cycles or discontinued study treatment.
% surviving without progression % surviving Results: PFS and OS Across Subgroups Median follow-up: 12. months All-treated Len-exposed but not refractory 1 8 PFS 12-month PFS, % 87% 71% 1 8 OS 12-month OS, % 9% 82% PI/IMiD-refractory 6 62% 6 75% 75% 4 51% Median: 14.1 mo 4 Median: 21.1 mo Median: 18.8 mo 2 2 No. at risk All-treated Len-exposed PI/IMiD-refractory 3 6 9 12 15 18 21 24 85 51 3 25 72 41 27 21 66 35 27 19 6 32 25 17 Months 26 12 13 6 13 6 7 2 11 5 6 1 8 3 5 1 No. at risk All-treated Len-exposed PI/IMiD-refractory 3 6 9 12 15 18 21 24 85 51 3 25 79 46 29 24 74 42 28 21 67 37 26 19 Months 34 19 13 11 18 1 7 4 16 9 6 3 11 5 5 2 Encouraging PFS observed in lenalidomide- and PI/IMiD-refractory patients; OS follow-up is ongoing PFS, progression-free survival; OS, overall survival; len, lenalidomide; PI, proteasome inhibitor; IMiD, immunomodulatory drug.
Conclusions D-Kd is safe and efficacious regardless of prior len exposure or refractoriness D-Kd was well tolerated with low neutropenia rates D-Kd induced deep and durable responses Median PFS was not reached with D-Kd for all treated patients with 12 months of median follow-up 14-month median PFS was encouraging for len-refractory patients Split first DARA dosing is feasible and may improve patient convenience for initial dosing Phase 3 randomized studies of D-Kd (CANDOR; NCT3158688) or pomalidomide plus dexamethasone (APOLLO; NCT318736) for len-exposed RRMM patients are ongoing